Medical Claims Auditor

WellSense Health Plan

6h•Remote

About The Position

The Medical Claims Auditor manages the process by which claims failing established clinical-related adjudication parameters are evaluated for payment. Leveraging clinical and/or coding expertise, the MCA considers a variety of factors including, but not limited to, Plan benefit, reimbursement and medical policies, provider contracts, correct coding guidelines, and adequacy of documentation of the service in question. This involves both the analysis of claims that have failed the adjudication process for clinical/coding-related reasons and the verification that services billed and paid were documented as having been provided.

Requirements

Bachelor's degree in Nursing with certification in coding either through AAPC or AHIMA or the equivalent combination of Coding Certification through AAPC or AHIMA, education, training and experience.
If a Registered Nurse: Minimum one year medical claim auditing or medical record review and Coding certification in AAPC or AHIMA.
If a Registered Nurse: Minimum two years RN experience in a clinical setting.
If a Certified Coder: Minimum seven years direct coding experience.
Successful completion of pre-employment background check.
Valid MA or NH Registered Nurse license or eligible OR valid AAPC or AHIMA coding certification.
Valid MA or NH Motor Vehicle Operator’s license and dependable transportation.
Proficiency in MS Office Suite.
General knowledge of medical claims processing systems.
Knowledge of general health insurance operations related to benefits/covered services, member and provider contracts, and medical and reimbursement policies.
Strong oral and written communication skills.
Ability to interact within all levels of the organization as well as with external contacts.
Ability to plan, organize and manage projects.
Detail oriented with strong analytical and problem solving skills.
Excellent proof reading and editing skills.
Ability to work well under pressure and respond to changing needs and complex environments.
Ability to compile, format, analyze, and present data to a variety of individuals, including management and providers.
Ability to work independently while contributing to the productivity of a team.
Regular and reliable attendance is an essential function of the position.

Nice To Haves

Two years’ experience in health care insurance, or provider coding or claims processing settings.

Responsibilities

Analyzes claims that have failed established clinical -related adjudication parameters by applying knowledge of CPT, HCPCS and ICD 10.
Establishes root cause of claims failure and applies Plan benefit, reimbursement and/or medical policies, contract terms, etc. to determine the appropriate resolution.
Prioritizes claims/cases based on urgency.
Consults staff in the Office of Affairs (OCA), Business Integration, Claims, Legal, claims, Benefits, Payment Policy, and other departments, as necessary, to resolve atypical issues.
Acts as internal consultant to various internal departments, such as Customer Care and Provider Relations, regarding clinical/coding-related adjudication parameters and their application in specific cases.
Applies, during the assigned clinical audits, knowledge of CPT, HCPCS, ICD10, provider contract terms, and Plan clinical and reimbursement policies to the validation of services in the medical record, and the accuracy of payment.
Documents clinical audit findings and communicates them to provider’s; records final audit findings and, where appropriate, processes recoveries or payments.
Identifies, during the analysis of failed claims or clinical audits, potential deficiencies in the delivery of care and refers to the appropriate department.
Identifies opportunities to improve or streamline clinical/coding-related adjudication parameters and/or their effect on claims processing and escalates to management for review and communication.
Maintains established productivity and quality metrics.
Other duties as assigned.
Provides technical assistance to less experienced staff members.